Primary Care Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: How should I code if a patient comes in for blood pressure (BP) monitoring only and the BP is within normal range? The doctor did not perform an examination or take a history.

California Subscriber

Answer: Use 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ) for the office visit. Unlike other office visit codes, billing 99211 does not require the physician to take a history or perform an exam. Documentation guidelines require only a chief complaint for 99211. Further, you can bill 99211 if a nurse takes the BP, as is the protocol in many family practices. When the nurse takes the BP, the doctor must sign the patient's chart.
 
If the patient is coming in for a screening, use V81.1 (Special screening for cardiovascular, respiratory, and genitourinary diseases; hypertension). Medicare will not reimburse the BP check in this case, so you will need to either charge the patient (assuming he or she has signed an advance beneficiary notice beforehand) or provide the BP check for free, as many practices do. If the patient has been diagnosed with hypertension and is returning for follow-up to check on his or her chronic condition, most payers will consider the BP check medically necessary. You should bill 99211 with 401.1 (Essential hypertension, benign).